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Waste Tire Sur ,y & Inspection Report Inspection Report Number <br /> Ilik State of Callfornia - <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 1 4 1 0 1 4 7 5 3 <br /> California Integrated Weste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> (Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: .3 C-) .7 -7 b •Routine Q Re-inspection Q Referral Q Observation <br /> Local r1� If Referral,choose referral type(Fill one) <br /> ci �N <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> - ����>^l.� �y <br /> Business or Facility Name I Inspected By Inspector <br /> Physical� ress <br /> l L4 3-3 <br /> Inspection Date l O :31 / c <br /> Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> QPM QPM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (9 Active I&Passenger Ile Generator I* Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader l0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFQR.GEMENTETATUS <br /> Y ; HAUL NQ ANIDWANI#,EST REQUIREMENTS <br /> Q O ! PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O No to Of V)Qistlon Qit4i1MfoR <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. COmpllana+8 [ldiid1116 <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Dote <br /> Q ® 14 CCR§18459.1 (a)(b)(c)-Tire Program 1D Number from ClWtAB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (�'er#rrlr,3a+fgr�l4flf <br /> Q 014 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years T y <br /> I <br /> Q ' Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Relerr�tdlt1t�li fffA�f � <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 <br /> 114 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § <br /> Comments <br /> Cc&" 141- Zoo-;' � � Olt- 5-2) / —7-7-.'-' <br /> .t <br /> Inspection FormIncluded; Q <br /> Comments Included: Q <br /> siness Rep's Slgnature Phone Number tor's Signature Phone Number <br /> INSTRUCTIONS ON BACKQ1� 4` Inc _ 62081 <br /> t t ._ E P L E A - I � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />